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The American Healthcare Conundrum

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Re: The American Healthcare Conundrum

#221

Post by sudopsuedo »

tptacek wrote: post #195

I buy that the locus of American overspending is in fees charged by providers (my understanding is that a further principle component of that spending is in end-of-life care). The problem, though, with going after pharma costs, and pharma benefit managers is that pharma is a relatively small component of overall spending; it's less than 10%. That is to say, you could make all pharmaceuticals entirely free, and we'd g…

The 9.2% figure is pharma's direct share of NHE, but drugs are a net-positive externality. Cheap statins can stave off cardiac surgeries, GLP-1 can stave off bariatric surgeries, etc. It's ridiculous to conclude we would only save 9.2% on costs--this is not zero-sum.

No comment on drug pricing and its incentives, the existence of America's prescription drug markets drives the new innovative drugs that the rest of the world picks up for cheap.

Re: The American Healthcare Conundrum

#222

Post by apical_dendrite »

timtim51251 wrote: post #7

Lots of people are saying nonsense here. The actual reason commercial insurers pay more is that's the only way to can make more profits. Because of Obamacare requiring 80% of the money they collect to be spent, the insurance companies just get to keep 20%. So insurance companies spend more so they can collect higher premiums. That's how they make more money. Several doctor friends have told me this as well.

My understanding is that there are a number of reasons why commercial insurance companies pay more. A big one is that Medicare has enormous pricing power because people on Medicare are a huge segment of the population and also the segment that consumes the most healthcare services. Your local healthcare system can't NOT take Medicare. They're effectively stuck with the reimbursement rates that Medicare sets. On the other hand, healthcare systems have a ton of power in their local markets. A healthcare system can afford to not be in network for a particular insurer, but if that insurer loses access to the biggest healthcare system in a particular market, it can be devastating for them. A major employer is not going to be happy if their executives have to all change doctors because the big local hospital system is no longer in network.

Re: The American Healthcare Conundrum

#223

Post by tptacek »

sudopsuedo wrote: post #221
tptacek wrote: post #195

I buy that the locus of American overspending is in fees charged by providers (my understanding is that a further principle component of that spending is in end-of-life care). The problem, though, with going after pharma costs, and pharma benefit managers is that pharma is a relatively small component of overall spending; it's less than 10%. That is to say, you could make all pharmaceuticals entirely free, and we'd g…

The 9.2% figure is pharma's direct share of NHE, but drugs are a net-positive externality. Cheap statins can stave off cardiac surgeries, GLP-1 can stave off bariatric surgeries, etc. It's ridiculous to conclude we would only save 9.2% on costs--this is not zero-sum. No comment on drug pricing and its incentives, the existence of America's prescription drug markets drives the new innovative drugs that the rest of the…

That's an interesting argument --- that massively increased access to pharmaceuticals would have knock-on impacts on other cost areas in the NHE.

I think if we dig into the numbers we're likely to find those effects, even if we maximize them, are marginal, unless we do other structural things to untangle the provider pricing system and do price transparency. Like: you could posit a material impact on CVD costs by making statins more widespread, and that should make a dent somewhere, but I don't know that CVD costs in non-Medicare-insured patients are really that big a line item, and non-Medicare is important here because people already Medicare-qualified generally have all the statins they want already. Meanwhile, providers are still ripping patients (and insurers) faces off for shoulder impingements, stents, and spinal fusions.

It's a super interesting comment. Thanks!

Re: The American Healthcare Conundrum

#224

Post by nradov »

raw_anon_1111 wrote: post #177
SV_BubbleTime wrote: post #168

Earlier quoted context omitted.

Costa Rica is a beautiful country. But it is in no way “first world”. It has no military, and is effectively dependent of the US and in best cases neighboring countries. It has excellent weather and soil which account for its fruits exports… and outside of some niche industry, is mostly reliant on tourism which means importing money. I love that country and have been many times. But if it were god forbid wiped off th…

Costa Rica purposefully got rid of its military so it could provide services. It didn’t feel a need to fund three unnecessary wars in two years. Guess which other country has universal healthcare - China. They are just slightly more populous than the US. > This isn’t some mechanism that the US just refuses to use. It’s a matter of scale. You either don’t know and should remain silent on the topic, or do know it and l…

Please stop spreading lies and propaganda. China does not have "universal healthcare" in any meaningful sense. They may claim to have it, but it's not something that poor people can actually access for expensive treatments. Patients have to pay out of pocket for most services.

Re: The American Healthcare Conundrum

#225

Post by ikr678 »

throw0101c wrote: post #173
twoodfin wrote: post #137

Earlier quoted context omitted.

Why is that inherently bad? Should I be able to buy fire insurance on pre-existing embers?

> Why is that inherently bad? Should I be able to buy fire insurance on pre-existing embers? What if someone gets Type 1 diabetes as a child so they can no longer get insurance because of that "pre-existing" condition: if they get cancer for unrelated reasons they should just be saddled with medical debt? Or because of your Type 1 you can't get coverage, and you get t-boned in your car by a drunk driver. Certainly it…

Pre-existing conditions also continue to frame healthcare as 'insurance' against a bad thing happening to you, when it should just be a regular service like any other.

You don't need 'insurance' in order to get your vehicle serviced, but that is what the US does with healthcare.

Re: The American Healthcare Conundrum

#226

Post by rayiner »

onraglanroad wrote: post #208
rayiner wrote: post #111

Earlier quoted context omitted.

> If this is correct, then how come there are so many complaints about insurance denying payment for healthcare or the hoops they make patients and doctors jump through for pre authorizations? Because those anecdotes get reader and viewer engagement. Charts comparing how much U.S. insurers pay on average for common procedures compared to, say, the UK NHS, don’t drive forward the narrative. You should interrogate the…

You should take your own advice and widen your media sources. Yes, you only get a continuous glucose monitor for free if you really need it on the NHS. If you want one otherwise you need to spend $100. It's not going to bankrupt you.

That’s the price for one monitor You need to buy a new monitor every 10-15 days. And your point about my media sources doesn’t make sense. As stated, I researched the coverage of continuous glucose monitoring because my friend got prescribed one.

The point isn’t that the UK NHS should cover CGM. I think they shouldn’t; it’s a waste of money unless you really need one. My point was about why the media pays so much attention to denials of coverage while you don’t hear about the over-coverage. You can’t go by the anecdotes. Talking about insurance covering unnecessary procedures doesn’t generate clicks.

Re: The American Healthcare Conundrum

#227

Post by shigawire »

cmiles8 wrote: post #3

Challenge is the whole system is just a mess. Medicare probably lays too little. Commercial insurers have formed a mountain of red tape and bureaucracy and arguably pay too much, although individual bills (EOBs) are rarely logically defensible against any scrutiny. Healthcare providers try and combat all this by literally just making up pricing and trying to negotiate something while also having bloated administrativ…

>Nothing about the current state of the healthcare system makes much sense to anyone that tries to peel back the onion.

I'd offer a slight tweak. None makes sense in a vacuum or solely considering efficiency. It all makes sense seeing the evolution over time and the misaligned incentives.

Re: The American Healthcare Conundrum

#228

Post by onraglanroad »

sudopsuedo wrote: post #221
tptacek wrote: post #195

I buy that the locus of American overspending is in fees charged by providers (my understanding is that a further principle component of that spending is in end-of-life care). The problem, though, with going after pharma costs, and pharma benefit managers is that pharma is a relatively small component of overall spending; it's less than 10%. That is to say, you could make all pharmaceuticals entirely free, and we'd g…

The 9.2% figure is pharma's direct share of NHE, but drugs are a net-positive externality. Cheap statins can stave off cardiac surgeries, GLP-1 can stave off bariatric surgeries, etc. It's ridiculous to conclude we would only save 9.2% on costs--this is not zero-sum. No comment on drug pricing and its incentives, the existence of America's prescription drug markets drives the new innovative drugs that the rest of the…

> the existence of America's prescription drug markets drives the new innovative drugs that the rest of the world picks up for cheap.

That's the ludicrous propaganda that you've been fed but you really should be intelligent enough to dismiss it.

The world would get along just fine without you overpaying for your drugs. You pay for marketing costs.

Re: The American Healthcare Conundrum

#229

Post by Manuel_D »

pixl97 wrote: post #77
glenstein wrote: post #52

Earlier quoted context omitted.

I will piggy back off of your comment because I was going to say a very similar thing. In my state, electric utilities are guaranteed a rate of return on investment of approximately 12%, if I remember correctly. And so there's a lot of incentive for build out and maintenance that's high in total dollar amount and high in volume of work done. In some ways it's the system working as designed but the "cap" can incentivi…

So you have an excessively built out electrical system... sounds like a win to me.

It's about threading the needle between a well funded grid, and an over engineered grid. There's a point where diminishing returns makes investment greater than that threshold wasteful relative to opportunity cost of spending that tax money on different public services.

Re: The American Healthcare Conundrum

#230

Post by shigawire »

WarmWash wrote: post #147
soared wrote: post #141

Earlier quoted context omitted.

[flagged]

Exactly, ask anyone in a job for the money how their week was. Not saying nursing is stress free, or every nurse is bad, but like tech companies in 2021, it's full of directionless people who pushed through the cert program to get paid $50/hr with $100/hr weekend shifts and be disgruntled with you that you are making them do work.

The disillusionment comes from hospital admins constantly squeezing blood from a stone.

Patient populations are up, nursing FTEs down. Support staff down.

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